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Background: Treatment-dose enoxaparin is not well studied in obese patients. Guidelines suggest that obese patients receiving enoxaparin therapy for acute venous thromboembolism (VTE) should receive a standard initial dose, 1 mg/kg, based on actual body weight. It is possible that this dosing strategy in obese patients may be overestimated, leading to a higher bleeding risk compared to non-obese patients. Objective: To gather data regarding enoxaparin treatment dosing and anti-Xa level monitoring in patients who are obese to guide dose adjustments. Methods: A single-center, retrospective chart review that included patients who were ordered treatment-dose enoxaparin and had a BMI ≥ 40 kg/m2, which resulted in an automatic pharmacy consult.The primary endpoint of this study was incidence of bleeding. Results: The analysis included 102 patients. Most patients (92.1%) had a BMI of ≥ 40-60 kg/m2 while 7.8% of patients had a BMI of > 60 kg/m2. The average initial and final doses were 1.0 ± 0.1 mg/kg and 0.9 ± 0.2 mg/kg, respectively. The incidence of bleeding was 4.9%. The average dose for those that bled was 0.7 ± 0.1 mg/kg. On average, patients who bled had higher BMIs than patients who did not bleed (51.6 kg/m2 vs. 48.0 kg/m2). Of the 71 patients with an initial anti-Xa level, 42 of the levels were considered supratherapeutic (59.2%). Conclusion: A 1 mg/kg starting dose of enoxaparin may be too high for patients who are obese as many patients required an adjustment to their dose after initial anti-Xa levels.

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Introduction Medications used to treat OUD have common metabolic pathways and pharmacodynamic properties that can lead to drug-drug interactions (DDIs) that may go unnoticed in the inpatient setting. The purpose of this study was to identify the frequency of DDIs between medications prescribed for OUD and commonly used inpatient medications. Methods This was a retrospective review of orders for buprenorphine, buprenorphine-naloxone, and methadone to identify potential DDIs. Adult inpatients with an order for one of these medications for OUD were included. Medication regimens were evaluated throughout the inpatient stay and on day of discharge for DDIs. DDIs were classified by severity and type of interaction (increased risk of QT prolongation, additive CNS effects/respiratory depression, and opioid withdrawal). The primary endpoint was the number of potential DDIs. Other endpoints included number of each classification/severity of DDI, duration of therapy of interacting medications, and modifications made to OUD medications because of DDIs. Results A total of 102 patients were included, with 215 inpatient interactions and 83 interactions at discharge identified. While inpatient, 85% of patients were on an interacting medication, and 46% of patients were on an interacting medication at discharge. The most common classification of DDI was additive CNS effects/respiratory depression (68.8% inpatient, 50.6% discharge), followed by QT prolongation (24.2% inpatient, 45.8% discharge). The majority of DDIs were classified as requiring close monitoring rather than contraindicated. Discussion There are opportunities to optimize the prescribing practices surrounding OUD medications in both the inpatient setting and at discharge to ensure patient safety.

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